How to make the best use of your health insurance
The first time I went to a doctor’s office in United States for a routine annual exam and blood work, I received a $1300 bill that I was responsible for paying. As a student, it was not an amount I could afford due to which I had to go on a payment plan. After that incident, I learned to be cautious and a need arose for me to be more educated and informed about the services I am paying for through my insurance premiums.
Last week, I switched from one health insurance to another. In doing so, it was an opportunity for me to understand the difference between the coverage offered by each. Despite being a mental health provider, I found it so difficult to understand the copay, deductible, and coinsurance amount I will be responsible for paying. I called the insurance companies and medical providers, trying to figure out if either of them could give me a specific amount I will be paying for a routine annual visit with some blood work. I asked the doctor about the services that would be covered by my insurance to which they replied, “Well, you need to call the insurance company and verify what your plan covers.” And the insurance company would not give me a specific amount unless I enrolled in their plan first because they “did not want to give me inaccurate information.” No body was helpful to say the least.
The insurance-related matters are so complicated that it would honestly prevent one from going to the doctors if they are going through financial issues. It could also be confusing to learn about the services that are available for FREE. However, it is extremely important for everyone to have an annual physical exam and recommended tests based on your age and gender to screen and to prevent any physiological conditions. What I ended up doing was reading the policy manual of the insurance in order to learn about my specific benefits. Here is what I learned:
According to US Preventative Services Task Force, the following services are covered at 100% by most insurance companies:
Annual preventive medical history and physical exam
Abdominal aortic aneurysm
Alcohol abuse and tobacco use
Colorectal, skin and lung cancer
Falls prevention and vitamin D use for stronger bones
High blood pressure, high cholesterol, obesity, diabetes and depression
Sexually transmitted infections, HIV, HPV and hepatitis
Healthy diet counseling
Sexually transmitted infections
Skin cancer prevention
Tobacco use, including certain medicine to stop
Use of aspirin to prevent heart attacks
JUST FOR WOMEN
Breast cancer screening, genetic testing and counseling
Breastfeeding support, supplies and counseling
Certain contraceptives and medical devices, morning after pill, and sterilization to prevent pregnancy
Cervical cancer screening
Chlamydia, gonorrhea, syphilis, HIV and hepatitis B screenings
Counseling for alcohol and tobacco use during pregnancy
Folic acid supplementation during pregnancy
Human papillomavirus (HPV) DNA test
Screenings during pregnancy, including screenings for anemia, gestational diabetes, bacteriuria, Rh(D) compatibility
Annual preventive medical history and physical exam
Dyslipidemia (for children at higher risk)
Hearing loss, hypothyroidism, sickle cell disease and phenylketonuria (PKU) in newborns
Hematocrit or hemoglobin
Sexually transmitted infections and HIV
ASSESSMENTS AND COUNSELING
Oral health risk assessment, dental caries prevention fluoride varnish and oral fluoride supplements
Skin cancer prevention counseling
Learn more on immunization recommendations and schedules by visiting:www.cdc.gov/vaccines
Diphtheria, Pertussis, Tetanus
Haemophilus Influenzae Type B (Hib)
Hepatitis A and B
Human Papillomavirus (HPV)
Inactivated Poliovirus (Polio)
Measles, Mumps, Rubella (MMR)
Varicella (Chicken Pox)
Zoster (Herpes, Shingles)
THESE PREVENTATIVE SERVICES ARE NOT SUBEJCT TO ANY COPAY, COINSURANCE, DEDUCTIBLE OR ANY OTHER INSURANCE TERM.
(Caveat: “The Affordable Care Act allows certain health insurance plans that went into effect before March 2010 to be considered “grandfathered,” meaning they are not required to cover 100 percent of preventive care services”)
WHY IS IT IMPORTANT TO MAKE GOOD USE OF THESE SERVICES:
I am not saying that you should use these services just because they are free. The most important reason is to stay on top of your physical and mental health. The preventive care includes services such as counselling, screening, and immunizations, which can help you and your family members stay healthy and keep a tab on your health status. The reason they are free is to reduce health care costs down the road because it is better to catch a problem early and treat it, than to let it develop.
IS THERE A CHANCE YOU MIGHT HAVE TO PAY?
Even though most of these services are covered at 100%, there are a few situations where you might have to pay
If you have an insurance plan that was grandfathered before March 2010 due to the Affordable Care Act, your preventive care services might not be covered at 100%
If the preventive care screenings uncover something, the doctor might request additional screenings, a follow up visit, and a specialist visit which might not be covered at 100%
If during our preventive screening, the doctors suggests that the treatment should start immediately, the visit might be considered a treatment visit as opposed to a preventive care visit.
WHAT CAN YOU DO TO STAY INFORMED ABOUT YOUR INSURANCE BENEFITS?
Read the benefits manual. If it is available online in a pdf format, download it, and search for “preventive” and see the list of services that you are completely covered for.
Whenever possible, call your insurance company ahead of time and check your benefits. Try and be as specific as you can whenever possible.
During the doctor’s visit, stay on the same page as the doctor and ask directly about the services your doctor is providing.
Once you get your bill, see if it matches with what you remember. Call the insurance company and confirm the services your doctors billed for, if there is a discrepancy.
Keep your paperwork. You can save a lot of time later if you keep your paperwork and bills handy.
Ask for reimbursement if your doctor made a mistake or charged you for services you did not request.
If your insurance does not cover these preventive services, I will encourage you to learn about your current benefits, see if they are adequate for your needs, and if not, look at other options if feasible.
Even though this article has a tone of “beware of the insurance companies and the doctors because they are out to get you” the goal is to stay skeptically curious, informed, and knowledgeable. Knowledge is power, and as consumers who pay for health care premiums, the least we can do is know what is available to us to maintain a good health.